THE BRITISH HEALTH DEBATE

- There is no competition in the health system in Britain

WRITING ON THE WALL -ASHOK V. DESAI

In India, a darzi means a tailor, and so probably does it in Armenia. But Lord Darzi is one of Britain’s most distinguished and influential surgeons. He was born in Iraq, whence he went to Dublin to study medicine in Trinity College. In 1991, he became consultant surgeon in Middlesex Hospital at the age of 31; in 1996, he became professor in Imperial College, London. He specialized in minimal invasive surgery, also known as keyhole surgery.

In 2006, NHS London, the local health authority, asked Darzi to tell it how to improve its working. He showed that people in East London, which has always been poor, live 7 years less, and have much fewer doctors per head. Originally, Britain nationalized doctors and expected them to provide primary healthcare. But in London, they were ever more concentrated in hospitals, so people were going to hospitals for minor problems. Darzi suggested something intermediate between doctors and hospitals called polyclinics: they would have doctors and investigation facilities, but would not be hospitals. Some of them would be urgent care centres, where people could go in accidents or emergencies. Minor operations could be done there without keeping patients overnight.

His report to London NHS was relevant and practical; it drew national attention. In 2007, Gordon Brown, the prime minister, appointed Darzi parliamentary undersecretary of state for health. Two weeks later he was raised to Lord Darzi of Denham, which presumably saved him the hassle of being elected to parliament. He was asked to make a review of the NHS. This time he adopted a different strategy; he asked clinicians all over the country to give their views. Some 2,000 contributed. The resulting report was not nearly as good as his own for London; there was much vague idealizing in it. But it had a central message: that what mattered in healthcare was quality, and that together with their annual financial accounts, healthcare providers should publish quality accounts. It envisaged a decentralized system. There would be local primary care trusts; they would represent patients. There would be regional strategic health authorities: they would manage the healthcare providers. The PCTs would buy medical services from the SHAs.

Quality was to be measured in terms of three parameters: patient safety, patient experience, and effectiveness of care. In other words, it was not enough that the patient should get good treatment; he had to feel that he had been treated with compassion, dignity and respect. Seven steps were worked out to raise quality: being clear about what was to be measured, measuring it, publishing data on quality, rewarding quality improvement, raising standards, safeguarding quality, and innovation. There would be no national enforcement of quality; each individual PCT would be required to aim at higher quality. But PCTs’ performance parameters would be published so that anyone could judge and compare them.

Meanwhile, the department of health also carried out an enormous opinion survey in 2006. It eventually covered 42,866 people. It found that while people were generally satisfied with the NHS, they wished that their doctors would give them more time, that various services would be coordinated and available together, that they provided the latest treatment, that treatment was available more quickly and readily for minor problems, and that the standards of treatment were the same across the country.

After the survey, the health department published a white paper, Our Health, Our Care, Our Say, which basically said that the government would do what the survey told it that people wanted: it would invest more in preventive services, give more support to emotional and mental well-being, listen more to people, and make sure they could go to a doctor of their choice close to them.

All these intentions were brought to an abrupt end when the Labour government was voted out of power in 2010. The Conservative government brought out its own white paper in 2010. Reflecting its own predilections, it said that it would cut the administrative costs of NHS by 45 per cent and save 20 billion pounds by 2014. But for the rest, it repeated many of the assurances given by the previous Labour government, for instance that patients would get information and have a voice in the treatment they received, would have a choice of doctors, and would be able to rate hospitals, that clinics and hospitals would have to meet national quality standards, and would be paid on performance.

But it has not been able to implement its election promises. Britain has two institutions that are supposed to act as representatives of patients: primary care trusts, which are essentially district-level public bodies, and consortia of doctors, who register patients and arrange treatment which they cannot themselves provide, for example in hospitals. The Conservatives wanted to abolish PCTs and leave patient servicing entirely to doctors; but they have not done so.

The Labour government had created a monitor to supervise major hospitals; but they largely ran themselves, and the monitor did not have much to do. The Conservatives had planned to turn it into an overall regulator for the NHS, and tell it to promote competition; but they have done nothing. They also wanted to transfer the overseeing of the NHS from the minister of health to the regulator. But their Liberal Democrat allies did not like that, so the minister continues to be in charge as he has been for over 60 years.

Thus, all British governments in the past decade and a half have come in with plans for radical restructuring of the National Health Service; but hitherto, they have achieved little. Competition is an ideal that appeals to non-socialists; but it is difficult to create competition in a monopolistic situation, especially where those who work for the monopoly are comfortable with it. Further, competition can make a difference only if there is surplus capacity; only then do buyers have a choice of sellers. There is no competition in the British health system. Every patient is attached to a general practitioner, as the British call their doctors. Patients can access hospital and other facilities only through their GP; and there is no surplus of GPs. And then, patients do not pay for medical services; the government does on their behalf. It has made noises from time to time that it would give them control over their medical expenditure; but it has not been able to work out how to do so.

Tony Blair had one idea: he made Lord Darzi deputy minister of health. If he had lasted, and left it to Darzi, quite possibly he might have found a workable solution. But Blair lost the election and went on to comfortable international assignments; I guess Lord Darzi went back to keyhole surgery. The British are generally good at government; but even they have been defeated by the NHS. They are handicapped by the fact that the British people are by and large quite satisfied with their NHS. They would like to see shorter waiting periods. That requires surplus capacity, which would be costly. The Conservative government wants to cut costs, which would cause shortages. The two are unlikely to agree.